To: Social Security Administration Re: ______ (Name of Patient) s1

To: Social Security Administration Re: ______(Name of Patient)

______(Social Security No.)

Please answer the following questions concerning your patient's impairments. Attach all relevant treatment notes, radiologist reports, laboratory and test results which have not been provided previously to the Social Security Administration.

1. Nature, frequency, and length of contact: ______

2 Does your patient fulfill the diagnostic criteria for systemic lupus erythematosus (SLE) identified by the American College of Rheumatology (namely, exhibit at any time at least four of the first eleven signs or symptoms listed in question #4 below? ___ Yes ___No

3. Other diagnoses: ______

4. Identify any clinical findings, laboratory and test results, symptoms and positive objective signs of your patient's impairment (or adverse effects of treatments):

___Malar rash (over the cheeks) ___Photosensitivity

___Discoid rash ___Oral ulcers

___Non-erosive arthritis involving pain in two or more peripheral joints.
Note if affected joints also exhibit persistent swelling, redness,
significant limitation of motion, tenderness, and/or warmth:
Affected joints: ______
______
___Cardiopulmonary involvement shown by pleurisy or low pericarditis

___Renal involvement shown by a) persistent proteinuria shown by:

___greater than 0.5gm/day or ___3+ on test sticks or ___cellular casts

___Central nervous system involvement shown by seizures and/or psychosis (in absence of drugs

or metabolic disturbances known to cause such effects)

___Hemolytic anemia or leucopenia (white blood count below 4,000/mm3) or lymphopenia (below

1,500 lymphocytes/mm3) or thrombocytopenia (below 100,000 platelets/mm3)

___Positive LE cell preparation or anti-DNA or anti-Sm anti-body or false positive serum test for

syphilis known to be positive for at least six months.

___Positive test for ANA at any point in time (in absence of drugs known to cause abnormality)

___Gastrointestinal complaints with:

___diarrhea or constipation ___nausea

___abdominal cramping or pain ___vomiting

___urinary urgency/incontinence

___severe fatigue ___severe weight loss ___severe fever

___severe malaise ___lupoid hepatomegaly ___impaired vision

___muscle weakness ___dermal vasculititis ___hair loss

___peripheral neuropathy ___Sjogren’s syndrome ___Peritonitis

___Avascular necrosis ___Migraine headaches ___poor sleep

___ Episodes of paralysis ___Easy brusing or changed ___Lymph node enlargement

due to central nervous blood clotting capacity

system involvement

___Raynaud’s ___Impaired muscle ___Frequent and

phenomenon coordination persistent infections

List any other signs or symptoms including any other renal or cardiopulmonary involvement: ______

______

5. Do emotional factors contribute to the severity of his/her symptoms and functional limitations? ___Yes ___No

6. Are your patient's impairments (physical impairments plus any emotional impairments) reasonably consistent with the symptoms and functional limitations described in this evaluation? ___Yes ___No

If no, please explain______

7. How often is your patient's experience of symptoms severe enough to interfere with attention and concentration?

___Never ___Seldom ___Often ___Frequently ___Constantly

8. To what degree can your patient tolerate work stress?

___Incapable of even "low stress" jobs ___Capable of low stress jobs

___Moderate stress is okay ___Capable of high stress work

If yes, Please explain the reasons for your conclusion: ______

9. Identify prescribed medications and treatments and the side effects of any medication (particularly of steroids, if applicable) which may have implications for working, e.g., dizziness, drowsiness, stomach upset, cataracts, liver damage, etc.: ______

______

10. Prognosis:______

11. Have your patient's impairments lasted or can they be expected to last at least 12 months? ___Yes ___No

12. As a result of your patient's impairments, estimate your patient's functional limitations if your patient were placed in a competitive work situation:

a. How many city blocks can your patient walk without rest? ______

b. Please circle the hours and/or minutes that your patient can sit at one time, e.g., before needing to get up, etc.

Sit: 0 5 10 15 20 30 45

Minutes

1 2 More than 2

Hours

c. Please circle the hours and/or minutes that your patient can stand at one time, e.g., before needing to sit down, walk around, etc.

Stand: 0 5 10 15 20 30 45

Minutes

1 2 More than 2

Hours

d. Please indicate how long your patient can sit and stand/walk total in an 8 hour working day (with normal breaks):

Sit Stand/walk

______less than 2 hours

______About 2 hours

______About 4 hours

______At least 6 hours

e. Does your patient need a job which permits shifting positions at will from sitting,

standing or walking? ___Yes ___No

f. Will your patient sometimes need to take unscheduled breaks during an 8 hour

working day? ___Yes ___No

If yes, 1) how often do you think this will happen? ______

2) how long (on average) will your patient have to rest

before returning to work? ______

3) on such a break, will your patient need to
___lie down or ___sit quietly?

g. While engaging in occasional standing/walking, must your patient use a cane or
other assistive device? ___Yes ___No

For the next two questions, "rarely" means 1% to 5% of an 8-hour working day; "occasionally" means 6% to 33% of an 8-hour working day; "frequently" means 34% to 66% of an 8-hour working day.

h. How many pounds can your patient lift and carry in a competitive work situation?

Never Rarely Occasionally Frequently

Less than 10 lbs. ______

10 lbs. ______

20 lbs. ______

50 lbs. ______

i. How often can your patient perform the following activities?

Never Rarely Occasionally Frequently

Twist ______

Stoop (bend) ______

Crouch ______

Climb ladders ______

Climb stairs ______

j. Does your patient have significant limitations in doing repetitive reaching,
handling, or fingering? ___Yes ___No

If yes, please indicate the percentage of time during an 8 hour working day on a competitive job that your patient can use hands/fingers/arms for the following repetitive activities:

HANDS:
Grasp, Turn, Twist Objects / FINGERS:
Fine Manipulations /
ARMS:
Reaching
(incl. Overhead)
Right: / ___% / ___% / ___%
Left: / ___% / ___% / ___%

k. State the degree to which your patient should avoid the following:

ENVIRONMENTAL RESTRICTIONS / NO
RESTRICTION / AVOID CONCENTRATED EXPOSURE /
AVOID EVEN MODERATE EXPOSURE / AVOID ALL EXPOSURE
Extreme cold / _____ / _____ / _____ / _____
Extreme heat / _____ / _____ / _____ / _____
High humidity / _____ / _____ / _____ / _____
Fumes, odors, dusts, gases / _____ / _____ / _____ / _____
Perfumes / _____ / _____ / _____ / _____
Cigarette smoke / _____ / _____ / _____ / _____
Soldering fluxes / _____ / _____ / _____ / _____
Solvents/
Cleaners / _____ / _____ / _____ / _____
Chemicals / _____ / _____ / _____ / _____

List other irritants or allergens: ______

l. Are patient's impairments likely to produce "good days" and "bad days"? ___Yes ___No

If yes, please estimate, on the average, how often your patient is likely to be absent from work as a result of the impairments or treatment:

___ Never ___ About one day per month

___ About two days per month ___ About three days per month

___ About four days per month ___ More than four days per month

13. Please describe any other limitations (such as psychological limitations, limited vision, difficulty hearing, etc.) that would affect your patient's ability to work at a regular job on a sustained basis: ______

______

14. What is the earliest date that the description of symptoms and limitations in this form applies? ______

______

Physician’s Signature Date form completed

Printed/Typed Name: ______

Address: ______

______ Return form to: Mike Murburg, PA

______15501 N. Florida Ave

Tampa, FL 33613

Tel: 813-264-5363

Fax: 813-514-9788